Provider Demographics
NPI:1275749350
Name:TOXICOLOGY ASSOCIATES PROF LLC
Entity Type:Organization
Organization Name:TOXICOLOGY ASSOCIATES PROF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SU
Authorized Official - Middle Name:
Authorized Official - Last Name:DIERBECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-765-3800
Mailing Address - Street 1:2555 S DOWNING ST
Mailing Address - Street 2:SUITE 260
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-5855
Mailing Address - Country:US
Mailing Address - Phone:303-765-3800
Mailing Address - Fax:303-765-3804
Practice Address - Street 1:2555 S DOWNING ST
Practice Address - Street 2:SUITE 260
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210-5855
Practice Address - Country:US
Practice Address - Phone:303-765-3800
Practice Address - Fax:303-765-3804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO22473174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01224732Medicaid
CO01345784Medicaid
CO01281856Medicaid
CO92374875Medicaid
COE75752Medicare UPIN
COF74622Medicare UPIN
CO01224732Medicaid
CO372718Medicare ID - Type Unspecified
CO538528Medicare ID - Type Unspecified
CO92374875Medicaid
CO01345784Medicaid